Pearson: Contraception Flashcards
What percent of contraception occur in women using contraception?
50-60%
What is method effectiveness?
THEORETICAL effectiveness if used PERFECTLY
What is user effectiveness?
ACTUAL effectiveness when studied in non-perfect world
What do natural methods require?
- requires female w/ regular, predictable cycles
- both partners dedicated
When does ovulation usually occur?
Prior to 1st day of menses
When should you avoid intercourse w/ the calendar method?
5 days prior and 3 days after ovulation
How do you determine the fertile period?
Subtract 18 days from length of shortest cycle
Subtract 11 days from length of longest cycle
How can you use basal body temps as a natural method?
see rise in temp w/ progesterone
Should drop again if not pregnant, but will sustain if pregnant
What is cervical mucous during ovulation?
egg white consistency (most abundant, watery,)
What is the best STI protection?
Condoms
*more effective and commonly used than F common
When are condoms most effective?
If used w/ spermacide, dependent on user
What form of barrier method increases rate of UTI and must be inserted up to two hours before sex and left in for at least 6 hours after (but removed before 24)?
diaphragms
*must be re-fit if more than 10# wght change
What for of barrier method must be left in minimum of 6 hours after sex (max of 48 hrs total)?
Cervical caps
What form of barrier method can be hard to fit, can increase the risk of cervical dysplasia and toxic shock?
cervical cap
What form of barrier method increases rate of yeast infections, UTI and TSS if left in place for extended periods?
sponge
How do you use spermicide formulations?
Used before insertion of diaphragm or cervical cap
• Works by damaging cell membranes of sperm cells and bacteria
• Can cause topical irritation (urethritis in men)
What is the mechanism of combined estrogen/progesterone methods?
estrogen-progesterone induced inhibition of the midcycle surge of gonadotropin secretion (prevent LH/FSH) from surging
- increases cervical mucous to prevent sperm penetration
- makes endometrium less hospitable
What are contraindications for combined estrogen/progesterone methods (pill, ring, transdermal patch)?
- Previous thromboembolic event or stroke
- Hx of CAD
- Hx of estrogen dependent tumor
- Liver disease
- Pregnancy
- Undiagnosed abnormal uterine bleeding
- Smoker over age 35
- Migraine headaches w/ neurologic symptoms
What are relative contraindications for combined estrogen/progesterone?
- Obesity
- Inherited thrombophilias
- Anticonvulsant therapy
- Migraine headaches
- Hypertension
- Depression
- Lactation
What are non contraceptive benefits of combined estrogen/progesterone?
- Reduction in dysmenorrea
- Reduction in menorrhagia
- Reduction of ovarian, endometrial, and colorectal cancers
- Improves acne
- Improves benign breast disease
- Improves osteopenia or osteoporosis
- Decreases functional ovarian cysts
- Decreases ectopic pregnancy rates
What medical concerns are associated w/ combined estrogen/progesterone?
• Increase in thromboembolic events (estrogenic component)
• Breast cancer risks – controversial and unproven
• Cervical cancer risks (more HPV than non sexually active women)
• Medication interactions
o Antimicrobials (Rifampin)
o Anticonvulsants
o Anti-HIV
o Herbal products (St. John’s Wort)
What are the components in “the pill”?
Estrogen (Ethinyl estradiol with doses from 10-50 mcg)
Progestin (varies)
What are Androgenic SE of “the pill”?
Earlier generations of the pill were more androgenic
- Increased LDL and/or decreased HDL
- Acne
- Hirsutism
What are general SE from “the pill”?
- Breast tenderness
- Nausea
- Headaches
- Mood changes- anxiety, irritability, depression
- Irregular bleeding/spotting
- Weight changes/fluid retention
What is the least androgenic first generation?
o Norethindrone- LEAST androgenic 1st/2nd generation progestin. Slight improvement in lipid profile which is different from other 1st / 2nd gen. pills. More androgenic than newer progestins
What is a second generation progestin that is highly prescribed and in many formulations like Plan B and extended cycle pills?
Levonorgestel
What third generation progestins are a good choice for pts w/ dyslipidemia, acne, or other possible androgenic SE but have HIGHER thromboembolic potential?
Norgestimate and Desogestrel
2-3x higher thromboembolitic potential than 1st/2nd gen progestins
What is Yaz (drospirenone)?
Spironolactone analogue
anti-mineralcorticoid/lower androgenic effects
What are potential benefits and risk of Yaz?
Potential benefits
— Improves weight stability/water retention
— Improves other possible androgenic SEs
Potential risk: increased serum potassium and VTE risk** (renal disease/diuretic)
What is dienogest?
One of the latest!
for long difficult periods
4 phases
marketed for metromennorhagia
same fixed soe for 3 wks than placebo
monophasic
varying dose throughout first 3 wks than placebo wk
biphasic, triphasic
84 days fixed dose hormones then placebo wk
Extended cycle (seasonale, lybrel)
- Lybrel – fixed dose of estrogen/progestin 365 days/yr
- Breakthrough bleeding more common but decreases over time
How do you prescribe the “right” pill?
- Start with low to moderate dose estrogen with appropriate progestin considering co-morbid conditions
- Allow at least 2-3 cycles to assess
- Adjust based on SEs
- Follow-up based on SEs and co-morbid conditions
How do you take the pills?
- First day of menses vs. Sunday start vs. quick start (to increase compliance)
- Take same time of day every day (if you want to switch the time wait until the next pill pack)
- Missed pills – take 2 the next day (if only missed 1) or may need to start over (if missed more than 1)
- Follow up: BP check, check for tolerance and SEs
What are common SE of “the pill”?
Breakthrough bleeding
o In first 10 days → increase estrogen
o After 10 days → increase progestin
No withdrawal bleed
o Do pregnancy test
o Continue pills
o If pt wants menses to return, can increase estrogen
Typical “hormone related SEs”
o Adjust appropriate hormone component
What hormones are in the NuvaRing?
15 mcg ethinyl estradiol and 120 mcg of etonogestrel daily
How is the NuvaRing used?
left in for 3 weeks then left out for 1
How does Nuva Ring compare to the Oral OCPs?
- Comparable efficacy
- Lower doses of hormones
- Rapid return to ovulation
- Ease and convenience
- Similar SE’s, contraindications
- Plastic NOT latex
What hormone combination is in the ortho evra patch?
20 mcg of ethinyl estradiol and 150 mcg of norelgestromin daily
How do you use the transdermal patch?
- Change once a week for 3 weeks then 1 week patch free
* Apply to buttock, abdomen, upper arm, or torso (not breast)
When should you use a back up method wtih the patch?
On for > 9 days, off for > 7 days
Falls off > 24 hrs
How does the patch compare to OCPs?
- Similar efficacy overall
- Greater failure rate in women >90 kg.
- Better compliance
- More breakthrough bleeding, breast discomfort, dysmenorrhea, site reactions
- FDA warning that women are exposed to more estrogen with patch than with most OCP’s- ?clinical implications long term
What is the purpose of emergency contraception?
prevention of pregnancy within 72-120 hours of unprotected intercourse or failure of a contraceptive method
What is the mechanism of emergency contraception?
depending on timing within menstrual cycle, can inhibit ovulation or prevent fertilization
How does EC relate to post-fertilization effects? Will it abort an established pregnancy?
- Greater possibility of a post-fertilization effect (if woman is later in her cycle) → endometrial changes inhospitable to a fertilized ovum
- Will NOT abort an established pregnancy
What is the mechanism of progesterone only pills?
inhibition of ovulation. The progestin effect also causes changes in the endometrium and cervical mucous → decreased sperm transport and implantation.
What are examples of progesterone only methods?
injection
oral (minipill)
IUD
implantable
What are indications for the progesterone only pills?
Patients who want effective contraception but want or need to avoid estrogen
o Medical contraindications to combo contraception
o Side effects to combo options that prohibit use
o Nursing
Prefer prescribing schedule
What issues should be considered w/ progesterone only pills?
- Irregular bleeding (WOMAN WILL NOT HAVE NORMAL PERIODS)
- Other SE’s from androgenicity
- Duration of effect and return to fertility
- Chance of breakthrough ovulation if “pill missed” w/ oral
- Effects on bone health (Depo)
What are the benefits of progesterone only?
- Eventual reduction of menstrual flow
- NO increased risk of stroke, MI, or thromboembolic event
- Reduced risk of endometrial cancer or PID (w/ Depo)
What instructions do you give a pt on the Minipill?
- First day vs. Sunday vs. immediate
- Take daily, like combo pill at same time every day
- No withdrawal bleed week
- Higher failure rate
- TIMING CRITICAL (within 3 hours) or backup contraception needed***
What is the injectable option of progesterone only?
• Medroxyprogesterone acetate (Depo-Provera)
IM every 3 months
What are concerns with Depo?
bone health (evidence for bone resorption and reduction in bone density → currently recommended for 2 year use!)
*recommend calcium and weight bearing exercise
How long does it take women to return to fertility?
up to 1 year
What are implanon and nexlpanon?
Progesterone only
- Rods implanted subQ under skin – remove once no longer effective
- Implanon/Nexplanon (etonogestrel) – 1 rod system, effective for 3 years
- Quick return to fertility
How do progesterone only methods affect fertility?
quick return to fertility except for depo
What is Plan B?
Progestin only
OTC for women of all reproductive ages
Less N/V
What is the effectiveness of Plan B?
95% effective in preventing pregnancy if used w/in 24 hours of unprotected sex
89% effective in preventing pregnancy if used w/in 72 hours of having unprotected sex
What is the benefit of Ella?
Can be used up to 5 days after unprotected sex
What is the mechanism of Ella and related SE?
- Progesterone agonist/antagonist
* SEs: HA, nausea, abd discomfort, dysmenorrhea, fatigue, dizziness
How do you dose a combo pill pack (estrogen and progestin) for emergency contraception?
Depending on estrogen/progestin dose, take 2 or 4 pills initially within 72 hours of unprotected intercourse and repeating dose in 12 hours
SEs: nausea
Can a copper IUD be used for emergency contraception?
YES!
What must you rule out before inserting an IUD?
GC/Chlamydia
What is the mechanism of the paragard IUD (copper)?
pre-fertilization effect; induces foreign body reaction in endometrium → inflammatory response preventing viable sperm from reaching fallopian tubes
How long is the copper IUD effective?
10 years
Who is a candidate for copper IUD?
- Want more regular periods
- Want no hormones
- No h/o dysmenorrhea
- No h/o menorrhagia
What is the mechanism of mirena-levonogestrel?
inhibits ovulation; inhibits sperm survival and implantation
What are non-contraceptive benefits of mirena?
↓ menstrual blood loss and relieves dysmenorrhea
How long is mirena affective?
5 years
Who is an appropriate candidate for mirena?
- OK w/ irregular bleeding and ammenorrhea
- H/o dysmenorrhea
- H/o menorrhagia
What is skyla?
mini version of mirena
effective for3 years
for nulliparous women
What is a tubal ligation?
- Laparoscopic procedure
- Ligation and section removal, clips, rings, coils, plugs, cauterization
- Can do during Cesarean section or postpartum
- Main adverse effects are surgery related
- If pregnancy does occur, higher risk for ectopic
- Post tubal ligation patients at decreased risk for ovarian cancer
What is a non-surgical tubal ligation?
• Essure and Adiana - **Less invasive, but 3 months of backup contraception needed **
What is a vasectomy?
Procedure that results in ligation of the vas deferens
How is a vasectomy performed?
In physician office under local anesthesia
Safe, effective
What are adverse effects of vasectomy?
procedural related
What post/procedure follow up should occur after a vasectomy?
o MUST have semen analysis to assure no motile sperm**
o Approx 20 ejaculations or 3 months following
o Need to use other form of contraception until cleared
